ART, male circumcision drives down HIV incidence in Uganda
SEATTLE — A Ugandan community with an historically significant place in the HIV/AIDS epidemic in Africa experienced a substantial long-term decline in HIV incidence following the scale-up of ART and male circumcision last decade, researchers reported here.
The 42% decline in HIV incidence in Rakai district, Uganda, over a 17-year period also coincided with a decrease in sexual activity among adolescents, according to a prospective study by Mary K. Grabowski, PhD, assistant scientist in the department of epidemiology at the Johns Hopkins Bloomberg School of Public Health, and colleagues.
The effectiveness of combination HIV prevention in sub-Saharan Africa has remained uncertain because of challenges in scaling up interventions and measuring population-level incidence. However, Grabowski said the results of their study show it can have a substantial impact over time.
“Our objective was to assess the real-world impact of a PEPFAR–sponsored scale-up of combination HIV prevention in an African setting,” she said during a news conference.
Rakai, a rural district in southern Uganda, was where the first HIV cases in East Africa were detected and was the epicenter of the regional epidemic in the 1980s, according to Grabowski. She said the district has a current mean HIV prevalence rate of 13% among persons aged 15 to 49 years.
Grabowski and colleagues collected data on 33,937 individuals in this age group from 30 communities in the Rakai Community Cohort Study between 1999 and 2016 and evaluated long-term trends in HIV incidence for their association with the scale-up of ART and male circumcision, population-level viral load suppression, and sexual behaviors.
They followed 17,870 initially HIV-negative persons of whom 931 later contracted the virus. These patients provided Grabowski and colleagues with 94,427 person-years of follow-up.
In 2004, a PEPFAR–supported ART program was introduced in Rakai. By 2016, self-reported ART use was 69% among patients with HIV, according to Grabowski and colleagues. This increase in treatment was accompanied by a significant rise in viral load suppression — defined as less than 1,000 copies/mL — from 42% in 2009 to 75% in 2016.
Scale-up of male circumcision was initiated in 2007, leading to an overall increase in coverage from 15% in 1999 to 60% in 2016, including an increase among non-Muslim men of 3.5% to 53%. Research has indicated that the procedure can decrease the spread of HIV in endemic communities.
As for sexual behavior, Grabowski and colleagues said the only substantive change was in patients aged 15 to 19 years who reported never having sex, which rose from 30% in 1999 to 55% in 2016. Grabowski said the proportion of adolescent males who reported multiple sexual partners declined from 40% in 1999 to 19% in 2016, but study results show that overall levels of self-reported condom use with nonmarital partners remained steady at around 40% in men and 30% in women.
Rakai district experienced a 42% reduction in HIV incidence relative to the time before the scale-up of ART and male circumcision — from 1.16 per 100 person-years to 0.66 per 100 person-years, according to Grabowski and colleagues.
The results included a 54% reduction in HIV incidence among males compared with a 32% reduction among females. Grabowski said the greater reduction of HIV incidence among males is likely because of the direct benefit of circumcision and an indirect result of the protective benefits of ART in HIV–positive female partners.
“We believe that our results provide strong evidence that PEPFAR–supported programs in sub-Saharan Africa are indeed effective for HIV control,” Grabowski said. – by Gerard Gallagher
Grabowski MK, et al. Abstract 34LB. Presented at: Conference on Retroviruses and Opportunistic Infections; Feb. 13-16, 2017; Seattle.
Disclosure: The researchers report funding from the NIH, CDC and Bill and Melinda Gates Foundation.